Abdo pain week 3 – management in ED

This series of posts will look at the best approach to assessing the child with abdo pain, and will cover the common conditions presenting to PED.  In this post we look at management of children in ED where there is no known cause for their pain.

When formulating your provisional and differential diagnosis for abdo pain, consider the following:

  • Be systematic
  • Most likely to least likely
  • Anatomical
  • Most serious
  • Surgical v non-surgical
  • Abdominal v extra-abdominal

And remember VINDICATEM (vascular, inflammatory/infectious, neoplastic, drugs, iatrogenic, congenital, autoimmune, traumatic, endocrine/environmental, metabolic).

Constipation is a not a diagnosis but must be explained by something.  Commonly this will be dietary but constipation can be a symptom of more significant pathology.  Whenever you attribute acute abdominal pain to constipation make sure you have done a thorough abdominal exam and considered more serious differentials in your formulation.  Always ensure appropriate follow up.

Consider the rarer but serious causes of abdo pain: discitis; ALL; intra-abdominal abscess; tumour.

What's in the list of differentials?

  • Appendicitis
  • UTI/pyelonpehritis
  • Testicular torsion
  • Cholecystitis
  • Pneumonia
  • Pancreatitis
  • Intussusception
  • Bowel obstruction
  • Meckel’s diverticulum
  • Poor diet (constipation)

Specifically remember extra-abdominal causes – tonsillitis/pharyngitis, pneumonia, and pericarditis.

And also medical causes – DKA, HSP, HUS, iron ingestion, FMF, and abdominal migraine.

What is more likely in neonates/infants?

In neonates/infants with abdo pain consider:

  • Hernia
  • Torsion
  • Appendicitis
  • NEC
  • Volvulus
  • Intussusception
  • Hirschprung

Assessment of abdo pain in ED can be tricky, particularly in the context of trying to differentiate between pain and anxiety. Use pain scales or visual analogue scales to help score pain.

How much pain relief can I give?

Simple analgesia should be given as appropriate. There are no RCTs on whether opioids are contra-indicated in children with abdo pain. In general, our practice should be to not withhold analgesia, and morphine or fentanyl can be given if needed.

Making the decision about discharge

This is difficult in children with abdo pain – should they be admitted and observed, or is it better to discharge them home?

If discharging, make sure the family have a solid plan for discharge and follow-up.

It may be appropriate to observe in an ED short-stay unit or under an inpatient team for 12-24 hours and perform a serial examination to assess progression of symptoms.

Bottom line:

  • Only a small percentage have a surgical cause
  • Age influences diagnostic possibilities
  • Abdominal examination is critical
  • Don’t withold analgesia
  • Aetiology may be intra or extra abdominal
  • Serial examination may be useful
  • Definitive diagnosis is not always possible
  • Clear follow-up is important